Leadless pacemakers as a new alternative for pacemaker lead-related superior vena cava syndrome: A case report

Superior vena cava (SVC) syndrome is a rare disease induced by thrombosis and consequent occlusion of SVC, negatively affecting morbidity and mortality. The incidence of SVC syndrome from central venous catheters and pacemaker or defibrillator leads is increasing. Optimal treatment of pacemaker or defibrillator-related SVC syndrome is not well defined. Lead extraction causes mechanical trauma to the vessel wall. In addition, subsequent device implantation on the contralateral side can be an added factor for venous occlusion. The use of leadless pacemakers could be an interesting option to reduce the risk of SVC restenosis after lead extraction. We report a clinical case of PM leads-related SVC syndrome referred to our centers and treated with transvenous lead extraction, leadless pacemaker implantation and subsequent percutaneous angioplasty and stenting of the SVC and left innominate vein.

New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS)

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consenus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology, (ACC) and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate follow-up in pediatric patients.

Central Venoplasty in Patients with Cardiac Implantable Electronic Devices

Objective The aim of this study was to assess the safety and effectiveness of the central venous angioplasty in patients with central venous occlusion and cardiac implantable electronic device (CIED) without lead extraction.

Materials and Methods A retrospective study was used to evaluate the effectiveness of 37 central venous angioplasty procedure for 15 patients with CIED without lead extraction.

Results Technical success was achieved in 97% (n = 36/37) and clinical success was achieved in 89% (33/37) of the procedures. One procedure failed recanalization of chronic total occlusion of the left subclavian vein, and the patient required fistula embolization due to severe arm swelling. Another procedure failed initially to recanalize long-segment occlusion involving the right subclavian vein/brachiocephalic vein and superior vena cava in a patient with a history of Hickman line and left-sided CIED. This was successfully recanalized and angioplastied on a subsequent session. No lead fracture or dislodgment was documented in any procedure. No procedure-related complication was documented within 2 weeks after the angioplasty. Six-month primary patency was achieved in 62% (23/37) of the procedures. Ten patients (66%) required an average of 1.4 reinterventions (range: 1–4 interventions) during the follow-up time with mean time to reintervention of 318 days (5–1,380 days). Two patients required early reinterventions within 10 days due to catheter dysfunction.

Conclusion Findings of this study support the existing evidence on the safety and effectiveness of balloon angioplasty without lead extraction.

Percutaneous management of superior vena cava syndrome in patients with cardiovascular implantable electronic devices

BACKGROUND

There is no consensus regarding the optimal management of cardiovascular implantable electronic device (CIED)-related superior vena cava (SVC) syndrome.

OBJECTIVE

We report our experience with transvenous lead extractions (TLEs) in the setting of symptomatic CIED-related SVC syndrome.

METHODS

We reviewed all TLEs performed at a high-volume center over a 14-year period and identified patients in which TLE was performed for symptomatic SVC syndrome. Patient characteristics, extraction details, percutaneous management of SVC occlusions, and clinical follow up data were analyzed.

RESULTS

Over a 14-year period, more than 1600 TLEs were performed. Of these, 16 patients underwent TLE for symptomatic SVC syndrome. The mean age was 53.1 ± 12.8 years, and 9 (56.3%) were men. Thirty-seven leads, with a mean dwell time of 5.8 years (range 2-12 years), were extracted. After extraction, 6 patients (37.5%) received an SVC stent. Balloon angioplasty was performed before stenting in 5 cases (31.3%). There was 1 major complication (6.3%) due to an SVC tear that was managed surgically with a favorable outcome. Eleven patients underwent reimplantation of a CIED. Over a median follow-up of 5.5 years (interquartile range 2.0-8.5 years), 12 patients (75%) remained free of symptoms.

CONCLUSION

Combining TLE with the percutaneous treatment of symptomatic SVC syndrome is a safe and viable treatment strategy.

Endovascular treatments of tunneled central venous catheter-induced superior vena cava complete occlusion via through-and-through technique

BACKGROUND

Superior vena cava occlusion (SVCO) induced by tunneled central venous catheter (tCVC) is an uncommon but challenging complication of hemodialysis patients. The aim of this study was to access the efficacy, safety, and patency of stents in tCVC-related SVCO via through-and-through technique.

METHOD

We retrospectively identified seven patients with benign SVCO secondary to tCVC treated with endovascular approaches successfully between 1 March 2013 and 31 October 2019. Patients' demographic data, clinical signs and symptoms, and imaging data were followed up and recorded.

RESULTS

Technical success was achieved in all cases. All the patients were performed with percutaneous transcatheter angioplasty (PTA) and subsequently stent placement via the through-and-through technique. During follow-up, four patients underwent secondary interventions, including PTA and/or stent placement. The primary patency after 3, 6, 9 and 12 months was 100%, 100%, 86% and 86%, and secondary patency after 12 months was 100%. No procedure-related deaths occurred.

CONCLUSIONS

Endovascular management of SVCO is a safe and effective approach. CT examination can provide a direction for endovascular treatment and periodic surveillance.

Lead-related superior vena cava syndrome: Management and outcomes

BACKGROUND

Superior vena cava (SVC) syndrome includes the clinical sequalae of facial and bilateral upper extremity edema, dizziness, and occasional syncope. Historically, most cases have been associated with malignancy and treatment is palliative. However, cardiac device leads have been identified as important nonmalignant causes of this syndrome. There are little data on the effectiveness of venoplasty and lead extraction in the management of these patients.

OBJECTIVE

The objective of this study was to report the findings associated with the use of balloon angioplasty and lead extraction in the management of 17 patients with lead induced SVC syndrome.

METHODS

Data collected from January 2003 to July 2019 identified 17 cases of SVC syndrome at our tertiary center. Their outcomes were compared to a control group of patients without SVC syndrome. A P value of <.05 was considered statistically significant.

RESULTS

Of the 17 patients, 13 (76%) underwent transvenous lead extraction and venoplasty. Three patients (18%) were treated with venoplasty alone, and 1 patient (6%) underwent surgical SVC reconstruction. In 10 patients (59%), transvenous reimplantation was necessary. Symptom resolution was achieved in all 17 patients and confirmed at both 6 and 12 months' follow-up. There was no significant difference in the rate of complications associated with transvenous lead extraction for SVC syndrome vs control.

CONCLUSION

In patients with SVC syndrome, venoplasty and lead extraction are safe and effective for resolution of symptoms and maintaining SVC patency.

Treatment of superior vena cava syndrome with kissing brachiocephalic stents and exchange of pacemaker leads

Superior vena cava syndrome is an uncommon but challenging complication of patients undergoing hemodialysis through upper extremity access as well as of patients with indwelling pacemakers. This case report and Video demonstrate the multidisciplinary management of a complex patient with hemodialysis access and indwelling pacemaker for whom multiple attempts at balloon angioplasty for superior vena cava syndrome failed. A joint procedure between vascular surgery and cardiac electrophysiology teams was performed to exchange the pacemaker leads and to place bilateral kissing stents in the brachiocephalic veins. The patient tolerated the procedure well and had no recurrence of symptoms.

The role of transvenous lead extraction in the management of redundant or malfunctioning pacemaker and defibrillator leads post ELECTRa

Cardiac implantable electronic devices implantation rates have increased over the past decade due to broader indications and an ageing population. Similarly, device and lead complications have also risen. The management of pacemaker/defibrillator leads that are no longer required (redundant) or malfunctioning, can be contentious. There is a need to balance the risk of transvenous lead extraction (TLE) against those of lead abandonment. The recently published European Lead Extraction ConTRolled Registry (ELECTRa) study provides contemporary outcomes for TLE across Europe with important implications for the management of redundant and/or malfunctioning leads. This review article discusses the potential complications for each interventional approach when managing redundant or malfunctioning pacemaker leads.

Mid-term Results of a Novel Dedicated Venous Stent for the Treatment of Chronic Thoracic Central Vein Obstruction of Benign Aetiology

OBJECTIVES

Endovascular treatment is indicated for the treatment of symptomatic thoracic central vein obstruction (TCVO) but is limited by high rates of restenosis and the need for re-intervention. The aim was to assess the safety and mid-term patency of a novel dedicated venous stent for the treatment of TCVO of benign aetiology.

METHODS

This was a prospective single centre observational study of 20 patients (median age 65 years, 50% male) referred for the treatment of symptomatic chronic (>three months duration) TCVO between May 2016 and January 2018. Balloon angioplasty with implantation of a self expanding nitinol stent (Vici, Boston Scientific, Marlborough, MA, USA) was performed in all patients. Clinical records including demographics, aetiologies and types of TCVO, and procedural details were recorded. Patients were followed up clinically at one, six, and 12 months. Primary and assisted primary patency were reported.

RESULTS

All 20 lesions were total occlusions, of which 55% (n = 11) were de novo, 10% (n = 2) peri-stent restenosis, and 35% (n = 7) in-stent re-occlusion. The aetiology of TCVO was predominantly (95%) because of multiple or prolonged central venous line insertion. The procedural success rate was 90% (18/20) with no procedural complications. The median follow up was 13.5 months. Primary patency was 100% at 6 months. One patient required re-intervention for stent in segment restenosis at 7 months. The assisted primary patency rate was 100% at 12 months.

CONCLUSION

Endovascular treatment of benign TCVO with the novel dedicated venous stent was safe and effective in relieving obstructive symptoms with excellent one year patency rates.

Change from Cardioinhibitory Syncope to Iatrogenic Positional Syncope: Superior Vena Cava Syndrome Treated by Superior Vena Cava Stenting and Leadless Pacemaker Implantation

Symptomatic obstruction of the superior vena cava can be caused by either intrathoracic malignancy or nonmalignant etiology, resulting in superior vena cava syndrome (SVCS). The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign SVCS. We present a post-pacemaker-implantation case of SVCS manifesting as positional syncope. The percutaneous intervention of stent implantation after lead removal followed by reimplantation of the leadless pacemaker may be a potential alternative treatment for pacemaker-induced SVCS, since some cases eventually may require repeat intervention.

A Review of Open and Endovascular Treatment of Superior Vena Cava Syndrome of Benign Aetiology

BACKGROUND

The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign superior vena cava syndrome (SVCS). This study aimed at reviewing the results of open and endovascular treatment of SVCS.

METHOD

Medical literature databases were searched for relevant studies. Studies with more than five adult patients, reporting separate results for the SVC were included. Nine studies reported the results of endovascular treatment of SVCS including 136 patients followed up for a mean of 11-48 months. Causes of SVCS were central venous catheters and pacemakers (80.6%), mediastinal fibrosis (13.7%), and other (5.6%). Percutaneous transluminal angioplasty (PTA) and stenting was performed in 73.6%, PTA only in 17.3%, and thrombolysis, PTA, and stenting in 9%. Four studies reported the results of open repair of SVCS including 87 patients followed up between 30 months and 10.9 years. The causes were mediastinal fibrosis (58.4%), catheters and pacemakers (28.5%), and other (13%). Operations performed included a spiral saphenous interposition graft, other vein graft, PTFE graft, and human allograft. Thirteen patients required re-operations (15%) before discharge mainly for graft thrombosis.

RESULTS

In the endovascular group technical success was 95.6%. Thirty day mortality was 0%. Regression of symptoms was reported in 97.3%. Thirty-two patients (26.9%) underwent 58 secondary procedures. In the open group the 30 day mortality was 0%. Symptom regression was reported in 93.5%. Twenty-four patients (28.4%) underwent a total of 33 secondary procedures.

CONCLUSIONS

Endovascular is the first line treatment for SVCS caused by intravenous devices, whereas surgery is most often performed for mediastinal fibrosis. Both treatments show good results regarding regression of the symptoms and mid-term primary patency, with a significant incidence of secondary interventions.

ICD Leads Extraction and Clearing of Access Way in a Patient With Superior Vena Cava Syndrome: Building A Tunnel

Central vein disease is defined as at least 50% narrowing up to total occlusion of central veins of the thorax including superior vena cava, brachiocephalic, subclavian, and internal jugular vein. Thrombosis due to intravascular leads occurs in approximately 30% to 45% of patients early or late after implantation of a pacemaker by transvenous access.In this case, we report a male patient, 65-years old, hypertensive, type 2 diabetic, with atherosclerotic disease, coronary artery disease, underwent coronary artery bypass surgery in the past 10 years, having already experienced an acute myocardial infarction, bearer automatic implantable cardioverter defibrillator for 8 years after an episode of aborted sudden death due to ischemic cardiomyopathy, presenting left superior vena cava syndrome. The use of clopidogrel and rivaroxaban for over a year had no benefit on symptoms improvement.After atrial and ventricular leads extraction, a new shock lead was positioned in the right ventricle using active fixation and a new atrial lead was positioned in the right atrium, passing inside of the stents. Two days after the procedure the patient was asymptomatic and was discharged.